Reporting in homecare - some states require various types of reports and other states do not; BUT regardless of what "they're making you do" it's best practices to keep timely and accurate reports to hold your agency to high standards. Capturing the information that you need to run an efficient agency in order to provide great customer service and client care helps set you up for success.
Here are those crucial pieces of information that we must capture:
Even with being successful, you're going to get complaints so we have to cover the topic. We don't like to admit that we get complaints, but sometimes even little ones are true complaints. Gripes, annoyances, the kinds of calls that make your staff roll their eyes, and the ones that give you anxiety; it makes you wonder if you're doing things right and you may even lose sleep right?
You want your clients to not only be satisfied, but happy. You also want them to feel valued, like they're getting the care they deserve or have coming to them. When they take the time to call, send an email, or fill out a client satisfaction survey, even with a negative score, they are in essence telling you, "I expected that I was going to get this, but I'm not getting it." This is how they're engaging your agency so it is important to listen to them and validate what they're saying. It should be recorded or documented. Document even if it's so that you can note that a particular woman calls every single day with a complaint - you're just gathering information about her, that may be helpful at some point. Sometimes the complaint is actually an incident which is important to document as well. Other times the complaint is just a conversation because somebody was bored. Either way, make sure that you're paying attention and capturing those complaints. Think of them as a gift.
An incident or occurrence is anything that's out of the ordinary; not covered in the client care plan or service plan. Falls and medication errors need to be reported. With medication, this includes whether the caregiver forgot to administer (staff responsibility) or if the client forgot to take it (client responsibility). A fall (even if it's a controlled fall) should be reported. In any case, it has to be addressed. How did it happen? How can we keep it from happening again? Was there an injury? Sometimes there are episodes of behaviors when somebody with dementia can be combative or aggressive. Then perhaps there are these behaviors and they don't have dementia and they're still combative or aggressive. Any of those types of incidents or occurrences have to be recorded for your clients' best care quality, but also to protect your agency!
Some incidents or complaints could be abuse, neglect, or exploitation. If that is the case, you always want to follow up with your state regulations and make sure you're protecting your clients by reporting these incidents to your local Adult Protective Services so that someone can advocate for them. You are advocating for them just by reporting.
For clients specifically, any infection is important to know about. A urinary tract infection, a respiratory infection, or a skin infection, all have to be reported for ongoing quality care. For staff, you generally only need to report communicable diseases like COVID, TB, or even the flu. Check CDC for what's listed as a communicable disease.
It's important not only to complete at least once within the lifetime of your client, but ideally at least once a year.
There are some people who complete client satisfaction every single month but that could get annoying to your clients if they have to answer the same questions too often. You might just want to determine this based on your client experience. You could find that they're not giving you real information. They're just hitting a button, saying or marking yes, and that does not give you the quality info you need. Remember we want quality, not just quantity.
If you find that most people don't respond to your Client Satisfaction Surveys, try creating an online survey and just sending a link by text. If you keep it short, most family members will comply. Survey Monkey or Google Forms are two easy ways to accomplish this.
As a nurse, I know if "It's not documented, it's not done". I've done videos about documentation before, but there's really a little more to it if you have to conduct Quality, Assurance, Performance, Improvement or QAPI.
Reports and documentation are your data. It's how you keep up with your services and performance, so it's a good idea even if you're not required. It's good business insight for determining how to improve business practices. This is a good way to tell the client's story and to provide great customer service.
"If I get hit by a bus..."
Real transparency is what we're looking for.
"We're aware that we're not perfect and we're addressing it. We are taking efforts and steps to train staff. If something goes wrong, we're making sure clients are protected, if they need to be."
An example of this is if a client's family calls and makes a special request and it isn't documented anywhere. Or, if there's been a couple of incidents that weren't documented, something bigger occurs, and we may not have that story to tell. Another example is if I get "hit by a bus." I knew about these things, but I got hit by a bus. If I don't keep track of client information in an organized system, whoever has to pick up where I left off is left without access to that information now.
Not only is that poor customer service, because obviously the ball was dropped, it can't even be picked up and run, with because nothing was reported. So transparency is important, especially if there are multiple people running your agency. Even if you're a sole owner operator, there should be some sort of backup person who needs access to what's going on with your clientele because you always need a contingency plan in case of an emergency.
Just remember everything needs to be documented somewhere in a centralized system. If you have reporting requirements through your state regulations and standards, then you're going to want to follow all of their recommendations. Even if you don't, it is a good practice to keep track of what's going on, if somebody is not happy, and if something out of the ordinary occurs. CYA (Cover Your Agency!)
Click below for this video on